Implementing a physical activity project for people with dementia in Germany–Identification of barriers and facilitator using consolidated framework for implementation research (CFIR): A qualitative study

Background Despite physical activity (PA) health benefits, people with dementia (PwD) continue to report low levels of PA engagement compared with healthy older adults. Evidencing that PA initiatives still not reflect effective practice and outcomes. Previous studies have shown that several factors can mediate PA initiatives implementation in this population. However, most prior research have not use implementation science frameworks to outline in-depth barriers and facilitators that enables improved PA strategies in PwD. Therefore, a more holistic understanding of mediating factors is still needed. Objective To identify multilevel barriers and facilitator factors, applying the Consolidated Framework for Implementation Research (CFIR) to orient a systematic evaluation of one PA project in PwD and provide evidence-based evaluation results to enhance PA implementation efforts for PwD. Method A qualitative study implemented in 4 German sports associations that applied a PA project for PwD. A total of 13 semi-structured interviews were conducted with 21 participants, project leaders (PLs) and sports trainers (STs). The Consolidated Framework for Implementation Research (CFIR) was used as an evaluation framework to orient both the data collection and analysis. Results A total of 13 interviews were conducted with 21 participants. The CFIR guided the identification of barriers and facilitating factors that need to be targeted at different levels for successful implementation. Barriers were identified, especially in the external level, as more solid networks and funding for sustainable proposals are still needed. Other barriers were low participation rates, stigma around the disease and the COVID 19 pandemic. On an individual and structural level facilitators were found like motivated appointed leaders, established planning process, and external organizations supporting sports associations in the implementation. Conclusion Sports projects for PwD can benefit from structuring their interventions based on the CFIR framework as it helps identify multilevel factors that may influence their success and promote PA among PwD. Future efforts should continue working on implementing frameworks that facilitate and reduce the complexity of implementing sustainable PA projects for PwD.


Response 2:
We thank the reviewer for this important comment. As a result, changes were made in the introduction to clarify what knowledge gaps are evident in the existing literature. We emphasised on the fact that although many studies have focused on identifying barriers and facilitators mediating physical activity outcomes, previous studies do not use scientific frameworks for implementation. Which outline in-depth barriers and facilitators at different levels that influence the success of interventions.
Line 93: "In spite of the existing evidence on the potential barriers and facilitators mediating PA outcomes in PwD, prior research did not provide a scientific angle using frameworks for implementation research. According to the most recent systematic reviews published in 2016 and 2018, studies synthesized barriers and facilitators to PA adherence in PwD, mainly including qualitative methodologies using data collection strategies like interviews and focus groups. However, to narrow the gap from research findings to practice, a comprehensive insight into the barriers and facilitators is required to bring more effective implementation strategies".
Line 116: "Regardless of the existence of such frameworks, their value to the field of dementia care and PA remains limited. Therefore, there is a need for further research that utilizes implementation science frameworks to outline in-depth barriers and facilitators of the intended change in practice at different levels to clarify the potential drivers of change and the challenging implementation dynamics and enable improved dementia care PA initiatives outcomes".

Point 3:
The authors should give justifications for using the CFIR framework in this study. Why did the authors choose the CFIR, but not others (e.g., the Theoretical Domains Framework). One of the major advantages of using the CFIR is that this framework has been widely applied. There are a few systematic reviews that have used the CFIR to investigate facilitators or barriers to implementing a health intervention. Please cite such publications when talking about the reasons for using the CFIR. One example is listed below. Please cite where appropriate.
Chan, P.Sf., Fang, Y., Wong, M.Cs. et al. Using Consolidated Framework for Implementation Research to investigate facilitators and barriers of implementing alcohol screening and brief intervention among primary care health professionals: a systematic review. Implementation Sci 16, 99 (2021). https://doi.org/10.1186/s13012-021-01170-8 Response 3: Many thanks for the valuable remark. The introduction was modified to justify why we chose the CFIR framework for the study. Moreover, we cited two more systematic reviews, in addition to the one suggested, to support the fact that this framework has been widely used.
Line 105: "One widely applied science framework is the Consolidated Framework for Implementation Research (CFIR) [21-23], which is used as a guiding tool for the multilevel assessment of implementation settings to detect facilitators and barriers to the successful implementation of interventions [22,23]. Furthermore, it offers a set of standardized and comprehensive implementation constructs, which account for characteristics that may influence implementation and thus play an essential role in whether or not interventions are successful [22,23]. Thus, this model groups these constructs into five domains: (1) Intervention characteristics (characteristics of the initiative likely to affect implementation); (2) Inner setting (organizational characteristics likely to affect implementation); (3) Outer setting (environmental characteristics likely to affect implementation); (4) Characteristics of individuals (persons engaged in the initiative likely to affect implementation); and (5) Implementation process (planning, executing, evaluating the intervention) [22, 23]".

Point 4:
For data analysis, this is a very important part. The authors should give details how the data coding of the data was performed. Any detailed approaches or procedures employed? Since the definitions of the CFIR constructs would be very different from the determinants of the study results, how were they matched? Given the current form, it is not clear about the data coding process.

Response 4:
Thank you for this remark. Again, it has been of great help in improving the clarity of the manuscript. Therefore, we have modified the text, adding a better description of how the data coding was performed, as follows: Line 241: "When developing the coding framework, we used a unified deductive and inductive category approach. In the case of the deductive categories, they were drawn out of the semistructured interview guide based on the CFIR domains and constructs, while the inductive subcategories arose at the time of the interview. Thus, interviews were used to explore further subcategories to identify areas relevant to a broader scope of discussion. To ensure the coding framework was comprehensive, interviews were thoroughly reviewed multiple times. In cases in which no other categories could be extracted from the interview transcripts, a line-by-line analysis of all the interviews was carried out using the coding framework".

Point 5:
It is expected that there should have some discussions about implementation strategies that address the determinants in order to improve physical activity among people with dementia. There are a host of implementation strategies. The authors should consider adding this section to the paper.

Response 5:
Thank you for the suggestion. We agree that it is crucial to consider some discussions about implementation strategies to address determinants and improve physical activity in people with dementia. However, in this paper, we decided to focus more on the implementation process and offer guidance on those determinants that might be needed to illuminate future interventions. Mainly since very few studies concentrate on methods and processes to achieve change in strategies for people with dementia.
Response to Reviewer # 2 Point 1: I have read and assessed the manuscript. I think the author studied a good topic about dementia patients which is a qualitative one with no needed statistical analysis. Concerning the language, it is acceptable with sound grammar and context. I think the author was able to include more interviews and participants, but the 20 is good.

Response 1:
Point 1: We appreciate the reviewers' time in revising the manuscript. We are sincerely thankful for their valuable comments and observations, which have greatly contributed to raising this manuscript's perceived quality.

Response to Reviewer # 3
Point 1: Firstly, the study's sample size is small and may not provide a comprehensive view of the subject under study. The study only included project leaders and sport trainers from four German sports associations, which could lead to sampling bias.
Response 1: we would like to thank you for your review and comments. As you mentioned, sampling is a crucial aspect of providing comprehensive results. Thus, we took seriously the sample size of this research. Since this is qualitative research, methodological studies in this field have shown that sample sizes between 17 and 40 participants achieve data saturation of meta-themes, guaranteeing rigorous quality (1)(2)(3). Furthermore, small sample sizes underpin detailed, in-depth case analysis, which is vital in this research approach (4). Accordingly, we believe that a sample of 21 participants is in line with the literature and enables a comprehensive view of the subject of the study.